Medical Records

Submitted by Guest on Mon, 27/07/2015 - 12:47

This screen displays the medical records for the current patient - or if there is no current patient, a Select button allowing you to select a patient.

Note that this screen is for viewing and editing the patient's medical records. However, if you are in the middle of a consult, you should not be using this - you should be using the Visit Editor which is accessed via the Consult button on the Workflow|Scheduling and Workflow|Work List screens.

All of these have a Select button at the top to allow you to select another patient.

All of them function as select screens. Date selection is always available, and in some you can select using the status or type.

All of them display the details of the item you have selected in the bottom part of the screen.

Summary

This shows the summary of the records. It should be obvious that the screen shot below is not taken from real practice data.

If you have set the Show Clinician preference, then the display will be as follows. Note that here the practice is using 'short names' for their clinicians (see Concepts|Users) so the display shows 'SM' rather than 'Dr Sam Michaels'.

Apart for the date, the selection fields are:Type - this can be set to All or one of Addendum, Note, Problem, Weight, Medication, Investigation, Attachment, Form, Image, or LetterInclude Charges - uncheck this box if you don't want to show the invoice line items. You would do this if you are setting up a medical record to send off as part of a referral and you don't want your charges to be shown. This option can also be set in Preferences. - this button changes the sort order of items within the visit - as shown it indicates that the visit items are shown in descending order, ie newest at the top. If you press the button it will change to an up arrow head indicating that the items are in ascending order with the newest at the bottom. Note that the visits themselves are always shown in descending order.
This option can also be set in Preferences.

The items in the display are partially colour coded. As you can see above, the selected item (the checkup visit) is in blue, and the other items are coloured as shown below.
As you can see problems are pink/red, medication light brown and weight a darker green. Note that any Problem items are shown with a link and clicking this will take you to the Problems tab.

The buttons are:New - create a new entry - a window will open allowing you to select the type of entry to be created. If it is something other than a visit (ie a note, a form, etc), then the new entry will be created under the currently selected visit. Note that the 'current visit' is the visit containing the currently selected item (which may be the visit itself or a note, form, medication etc item that is part of that visit).
With the exception of Visit and Problem records, records can be automatically locked from editing after a period of time. See Medical Record Locking below.Edit - edit the selected item. If the Edit button is displayed, then you can edit the item - but for some things (e.g. an invoice item where the invoice has been finalised, or a Note that has been locked) the edit button will be suppressed because you cannot edit in this case.Delete - delete the selected item - a confirmation window will be displayed. Again, if you can't delete the item, then the Delete button will not be displayed.Print - print what is shown on on the screen (or preview it or email it)Add Visit & Note - pressing this will generate a new visit entry (with Reason 'No Reason') and open the Create/Edit Note window so that you can add a note. This button should NOT be used to create a normal consult visit (for this you should use the Check-In button on the Workflow|Scheduling screen). It is intended for use when creating a note unrelated to another visit, say as a result of a phone call.Import Flow Sheet Reports - imports Medical Records, Billing, Notes and Flow Sheet PDF reports from Smart Flow Sheet. Only displayed if Smart Flow Sheet is configured for the current Practice Location.

Problems

The Problems tab shows the details of the patient's problems. This tab mirrors the Summary tab display but shows the data grouped by problem rather than visit. Visits are shown with a link and clicking this will return you to the Summary tab.

The buttons are as follows:New - create a new entry - a window will open allowing you to select the type of entry to be created. If it is something other than a problem (ie a note, a form, etc), then the new entry will be created under the currently selected problem. Note that the 'current problem' is the problem containing the currently selected item (which may be the problem itself or a note, form, medication etc item that is part of that problem).Edit - edit the selected item. If the Edit button is displayed, then you can edit the item - but for some things (eg a invoice item where the invoice has been finalised) the edit button will be suppressed because you cannot edit in this case.Delete - delete the selected item - a confirmation window will be displayed. Again, if you can't delete the item, then the Delete button will not be displayed.Print - print what is shown on on the screen (or preview it or email it)

Reminders/Alerts

The Reminders/Alerts tab shows the details of the patient's reminders and alerts.

For details on the Alerts fields click here, for Reminders click here.

The buttons are as follows:New - create a new alert or reminderEdit - edit the selected itemDelete - delete the selected item - a confirmation window will be displayed

Documents

This shows the details of the patient's documents. As you can see below, there are 5 different types: Attachments, Images,Investigations, Letters and Forms. All of these except the latter support 'versions', ie previous revisions of the document.

The buttons are:New - create a new document - a window will open allowing you to select the typeEdit - edit the selected document record (not the document itself - though see below). If the document has status Finalised you will not be able to edit the record.Delete - delete the selected document - a confirmation window will be displayed. If the document has status Finalised you will not be able to delete it.Print - if the selected item has an associated document template (which can be the case with an Investigation - see Administration|Types|Investigation) this will be presented for printing. Otherwise, if there is an attachment present, in .odt or .doc format, it will be presented for printing. If the document is other than an .odt or .doc file, it will be downloaded and can then be printed.Refresh - (this button only appears when the selected document is a Letter) - refresh the document by regenerating it from its template - a confirmation window will be displayed.

Clicking on the entry in the Document column will cause the document to be downloaded and displayed. Note that for Letters the Document column shows two icons like . If you click on the right-hand one, the pdf file containing the letter will be downloaded and displayed. If you click on the left-hand one (or the name of the document) then the word processing document will be downloaded and you can open it in your word processor and save it and then edit it. (You need to save it as it is opened read-only.) After editing the file, you can then use the Edit button to edit the letter and upload the revised file.

Charges

This shows the details of the charges resulting from the patient's treatments. Note that this screen just displays information, there are no 'bottom buttons' to let you do things. It is provided so that you can check that everything you think should be charged for has been, and to check on past charges.